Presented by:

Maryann Tomkins, PTA, ATP, RRTS

In this one hour course we will discuss :

The advocacy mandate in the Code of Ethical Conduct for Physical and Occupational Therapy

Who qualifies for a wheelchair based on algorithmic assessment

The difference between a DME provider and a Complex Rehab Specialist.

Proper procedure for acquiring equipment based on Medicare’s categories of wheel chairs

How to advocate for your profession and the patients you serve

Quote of the Day:

Life is 10% what happens to you and 90% how you react to it.

-Charles Swindoll

ad⋅vo⋅ca⋅cy [ad-vuh-kuh-see]

noun: the act of pleading for, supporting, or recommending; active espousal.

“He was known for his advocacy of states' rights.”

Dictionary.com UnabridgedBased on the Random House Dictionary, © Random House, Inc. 2009.

4755-27-05 Code of Ethical Conduct:Physical Therapists and Physical Therapist Assistants

Ethical integrity:

A licensee shall be guided by concern for the physical, psychosocial, and socioeconomic welfare of patients

A licensee shall strive to effect changes that benefit the patient.

A licensee shall ensure the patient’s rights to participate fully in their care, including the patient’s right to select the physical therapy provider, regardless of the practice setting

A licensee shall safeguard the public from underutilization or overutilization of physical therapy services.

4755-7-08 Code of Ethics:Occupational Therapy

Ethical Conduct:

Occupational therapy practitioner shall demonstrate a concern for the well-being of their clients.

Occupational therapy practitioners shall make every effort to advocate for clients to obtain needed services through available means.

Occupational therapy practitioners shall accurately represent the qualifications, views, contributions, and findings of colleagues.

The intent of (ethics) complaint is to protect the public.

Ohio Revised Code: Ohio Counselor, Social Worker, and Marriage & Family Therapist Board

Any person having reasonable cause to believe that an adult has suffered abuse, neglect, or exploitation may report, or cause reports to be made of such belief to the department

Any person with reasonable cause to believe that an adult is suffering abuse, neglect, or exploitation who makes a report pursuant to this section or who testifies in any administrative or judicial proceeding arising from such a report, or any employee of the state or any of its subdivisions who is discharging responsibilities under section 5101.62 of the Revised Code shall be immune from civil or criminal liability on account of such investigation, report, or testimony, except liability for perjury, unless the person has acted in bad faith or with malicious purpose.

RESNA BYLAWS:For Assistive Technology Professionals

Rehabilitation Engineering and Assistive Technology

Society of North America (RESNA)

The purpose shall be to contribute to the public welfare through scientific, literary, professional and educational activities by supporting the

development, dissemination, and utilization of knowledge and practice of rehabilitation and assistive technology

in order to achieve the highest quality of life for all citizens.

So…what is your excuse?

Apathy???

- the trait of lacking enthusiasm for or interest in things

-generally, the trait of remaining inactive

- a lack of initiative

So…what is your excuse?

Anxiety???

-a state of uneasiness and apprehension about future uncertainties

-fear resulting from the anticipation of a realistic or fantasized threatening event or situation

Understanding

Medicare

and

Medicaid

(aka: CMS)

CMS…what is it? July 1, 2001: Reorganization & name change to…

Centers for Medicare & Medicaid Services (CMS). (CMS is an operating division of the Health and Human Services Department)

The Mission: promote the timely delivery of quality health care

Mandate:

Ensure beneficiaries are aware of the services for which they are eligible

Ensure services are accessible

Ensure services are of high quality

Ensure agency policies and actions promote efficiency and quality

http://legal-dictionary.thefreedictionary.com/Centers+for+Medicare+&+Medicaid+Services

MEDICARE-At a Glance:

1935-Social Security Act

1965-Social Security Amendment introduced the “Entitlement to Hospital Insurance Benefits ” known as Medicare

2003-Medicare Modernization Act-adding prescription drug coverage

From: http://www.cms.hhs.gov/History/

MEDICARE-At a Glance:

Medicare is a health insurance program for:

people age 65 or older,

people under age 65 with certain disabilities, and

people of all ages with End-Stage Renal Disease

It offer 3 types of coverage:

Part A Hospital Insurance- Most people do not pay a premium

Part B Medical Insurance - Most people pay a monthly premium

May include, but not limited to doctor’s services, DME, ambulance, x-rays, lab tests outpatient PT/OT/SLP and mental health services chiropractic care, home health services

Prescription Drug Coverage- Most people pay a monthly premium(http://www.cms.hhs.gov/MedicareGenInfo-/10/05/09)

Medicare Facts:

Medicare expenditures for 2007 = $453 billion.

Total waste, fraud and abuse in Medicare was about $70 billion, or about 15.4 percent of total Medicare expenditures.

Medicare DME spending for 2007 =$9.8 billion

$700 million was attributed to waste, fraud and abuse, or approximately 7 percent of total Medicare spending for DME.

http://homecaremag.com/mag/durable-medical-equipment-fraud-reality-200904/

http://www.amsa.org/business/Medicare%20Report.pdf

MEDICAID-At a glance:

The Medicaid program began in 1965

Each state receives federal matching funds

A state administered program and each state sets its own guidelines regarding eligibility and services

Provides health care services to:

low-income children deprived of parental support, their caretaker relatives

the elderly

the blind

individuals with disabilities who fit into an eligibility group that is recognized by federal and state law.

MEDICAID-At a glance-legislation:

Deficit Reduction Act (DRA) of 2005:

Created the Medicaid Integrity Program (MIP) to prevent and reduce provider fraud, waste, and abuse.

American Recovery and Reinvestment Act of 2009 (ARRA):

Federal Medical Assistance Percentage (FMAP)

The amount of matching federal dollars a state receives is based upon the state's relative wealth.

Increased FMAP payments an additional 6.2 percent from FY 2009 to first quarter of FY 2011.

Ohio will receive more than 3 billion under this program

FMAP FY2009=62.1% FMSP FY2009 w/ ARRA Adjustment=72.3%

Medicaid fact sheet: Federal Medicaid expenditures FY 2007 =~$320 billion

Federal percentage= 56.7% State percentage= 43.3%

Ohio Medicaid expenditures FY 2007=~$13 billion

Ohio expenditures on supplies and equipment (includes DME):

~$157 million or 1.7% of the fee for service expenditures

http://www.cbpp.org/cms/index.cfm?fa=view&id=2647

From: http://www.cms.hhs.gov/History/

http://www.cms.hhs.gov/Recovery/09_Medicaid.asp

http://www.statehealthfacts.org/profileind.jsp?ind=695&cat=4&rgn=37

www.communitysolutions.com/images/upload/.../sbmv5RW4.pdf

Overview

Medicaid vs. Medicare

Medicaid Medicare-Aid for some poor Ohioans -Care for nearly all Ohio seniors-Must have low income -No income limit-Children, parents, disabled,& age 65+ -Age 65+& some people w/ disabilities-Primary, acute and long-term care -Primary and acute care only-State and Federal funding -Federal funding-No payroll deduction -Payroll deduction

http://www.healthpolicyohio.org/pdf/MedicaidBasics_2009.pdf

Are we all clear on CMS?

DMEand

You!

Medicare’s Provisioning of Durable Medical Equipment

Durable Medical Equipment (DME) is equipment which:

Can withstand repeated use;

Is primarily and customarily used to serve a medical purpose rather than convenience or comfort;

Generally is not useful to a person in the absence of an illness or injury;

Is appropriate for use in the home; and

As prescribed by a physician.

All requirements of the definition must be met before an item can be considered to be durable medical equipment

DME cont.:

DME includes Mobility Assistive Equipment or MAE (such as canes, walkers, wheelchairs, power scooters…), hospital beds and portable oxygen equipment.

DMEPOS: Medicare also covers prosthetics, orthotics and certain supplies (POS). Prosthetics are devices that can replace a missing body part, such as a hand or leg. Orthotics are equipment like braces that help to support or correct the malfunction of a limb or torso.

In most cases, Medicare does not cover medical supplies that generally are used and then thrown away.

DME &Complex Rehab products

Complex Rehab products are DME products that include manual and

power wheelchair systems, adaptive seating, alternative positioning,

and other devices that require substantial evaluation, fitting,

configuring, adjusting, or programming to meet the specific and unique

needs of an individual with significant postural or mobility deficits.

Why does this matter?

Mobility Assistive Equipment (MAE) is reasonable and necessary for:

Beneficiaries who have a personal mobility deficit

Which impairs toileting, feeding, dressing, grooming, and bathing

Aka: Mobility related activity of daily living (MRADL)

in customary locations within the home

Effective May 5, 2005

The beneficiary, the beneficiary’s family or other caregiver, or a clinician, initiates the discussion and consideration of MAE

Thinking like CMS…

The Algorithmic process

Does a mobility limitation exist that significantly

impairs his/her ability to participate in one or more

MRADLs in the home?

The Algorithmic process cont. Can the functional mobility deficit be sufficiently

resolved by the prescription of a cane or walker?

The Algorithmic process cont.

Does the beneficiary have sufficient upper extremity function

to propel a manual wheelchair?

The Algorithmic process cont.

Does the beneficiary have sufficient strength and

postural stability to operate a POV/scooter?

The Algorithmic process cont.

Are the additional features provided by a power

wheelchair needed to allow participation in one or

more MRADLs?

The Algorithmic process…a recap Does a mobility limitation exist that significantly impairs his/her ability to

participate in one or more MRADLs in the home?

Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or walker?

Does the beneficiary have sufficient upper extremity function to propel a manual wheelchair

the beneficiary have sufficient strength and postural stability to operate a POV/scooter?

Are the additional features provided by a power wheelchair needed to allow participation in one or more MRADLs?

Now that you understand CMS…

Lets move on!

Medicare Supplier Standards

In order to receive or retain Medicare billing privileges, all DMEPOS suppliers must comply with the Medicare program's supplier standards and quality standards to become accredited by Oct. 1, 2009.

The supplier shall govern its business so that it obtains and provides appropriate quality equipment, item(s), and service(s) to beneficiaries.

The supplier shall have a physical location and display all licenses, certificates, and permits to operate. The licenses, certificates and permits must be displayed in an area accessible to customers and patients.

Medicare Supplier Standards, cont.

Implement policies and issue job descriptions that specify personnel qualifications, training, certifications &licensures where applicable, experience, and continuing education requirements consistent with the specialized equipment, items, and services it provides to beneficiaries

Technical personnel shall be competent to deliver and set-up equipment, item(s) and service(s) and train beneficiaries and/or caregiver(s). Professional personnel shall be licensed, certified, or registered and function within their scope of practice.

http://www.cms.hhs.gov/MedicareProviderSupEnroll/Downloads/DMEPOSAccreditationStandards.pdf

The Medicare Procurement Process:

For manual wheelchairs including Tilt in Space:

PRESCRIPTION FROM DOCTOR FOR PT/OT EVAL ANDFOR W/C

SIGNED MEDICAL RELEASE FORM (for Sonshine)

LMN / EVAL w/ JUSTIFICATION of EQUIPMENT

HOME ASSESSMENT (Sonshine)

DETAILED PRODUCT DESCRIPTION (Sonshine)

SENT TO ADMC (Sonshine)

ORDER CHAIR (if medical necessity proved)

DELIVER CHAIR w/MEDICARE STANDARDS(Sonshine)

The Procurement Process: cont. MEDICARE CHECK LIST FOR POWER MOBILITY:

PRESCRIPTION FROM DOCTOR FOR PT/OT EVAL AND FOR W/C FACE TO FACE VISIT PRESCRIPTION- 7 ITEMS LMN / EVAL w/ JUSTIFICATION of EQUIPMENT SIGNED MEDICAL RELEASE FORM (for Sonshine) CHART NOTES (from MD/therapy/x-rays) DATE STAMPS (Sonshine) HOME ASSESSMENT (Sonshine) DETAILED PRODUCT DESCRIPTION (Sonshine) SEND ALL INFO TO ADMC IF APPLICABLE (Sonshine) DELIVER CHAIR w/ MEDICARE STANDARDS & RENTAL PURCHASE OPTION

(Sonshine)

ADMC=Advanced Determination of Medicare Coverage

Answer: “ CMS and the diagnosis.”

CMS Adult manual wheelchair HCPC Codes:

K0001 Standard wheelchair

K0002 Standard hemi (low seat) wheelchair

K0003 Lightweight wheelchair

K0004 High strength, lightweight wheelchair

K0005 Ultra lightweight wheelchair

K0006 Heavy duty wheelchair

K0007 Extra heavy duty wheelchair

K0009 Other manual wheelchair/base

E1161 Manual adult size wheelchair, includes tilt in space

CMS MANUAL WHEELCHAIR HCPC Codes (cont.):

E1229 Wheelchair, pediatric size, not specified

E1231Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, w/ seating

E1232 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, w/ seating

E1233Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, w/o seating

E1234Wheelchair, pediatric size, tilt-in-space, folding, adjustable, w/o seating

E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system

E1236 Wheelchair, pediatric size, folding, adjustable, with seating system

E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system

E1238 Wheelchair, pediatric size, folding, adjustable, without seating system

The Power Groupings:

The Basic Coverage Criteria for all powered mobility …think of the algorithm:

Patient has a mobility limitation that impairs his/her ability to perform 1 or more Mobility Related Activities of Daily Living (MRADL)

The limitation cannot be resolved with a cane or walker

Patient doesn’t have sufficient UE function to operate a manual wheelchair (MWC) in the home

Group 1 -Power Operated Vehicle(POV)

POV/ Scooter-K0800 Coverage Criteria The patient is able to:

Safely transfer to and from a POV, and

Operate the tiller steering system, and

Maintain postural stability and position while operating the POV in the home.

The patient’s mental capabilities (e.g., cognition) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home.

The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided.

The patient’s weight is less than or equal to the weight capacity of the POV that is provided.

Use of a POV will significantly improve the patient’s ability to participate in MRADLs and the patient will use it in the home.

The patient has not expressed an unwillingness to use a POV in the home.

Allowable:$1,169.96

Power Coverage Criteria for Groups 2-5:Rule Out Scooter/POV

The patient can’t transfer to /from a POV, operate the tiller, or maintain stability while operating or

The patient’s mental and physical capabilities are insufficient to operate a POV in the home; or

The patient’s home does not provide adequate access to operate a POV in the home

Power Wheelchair Coverage Criteria

The patient has the mental/physical capabilities to safely operate the power wheelchair provided; or

The patient has a caregiver who is unable to adequately propel an optimally configured MWC, but is available, willing, and able to safely operate the power wheelchair provided; and

The patient’s weight is < or = to the weight capacity of the power wheelchair that is provided; and

The patient’s home provides adequate accessfor the operation of the power wheelchair; and

Use of a power wheelchair will significantly improve the participation in MRADLs in the home; and

The patient has not expressed an unwillingness to use a power wheelchair in the home

The Power Groupings cont.:

Group 2 -No Power Options

HCPC codes: K0822, K0823, K0824, K0830, K0831

No powered seating options

Specialty evaluation not required

Allowables: $3,617.70-$4,382.64

The Power Groupings: contGroup 2- Single Power Option

HCPC code: K0835

Additional Coverage Criteria

The patient requires a drive control interface other than a hand or chin-operated standard proportional joystick; or

The patient meets coverage criteria for a power tilt or recline seating system and the system is being used on the wheelchair; and

The patient has had a specialty evaluation performed by a PT/OT, or physician who documents the medical necessity for the wheelchair and its special features.

Allowables: $3,671.90

The Power Groupings: contGroup 3- No Power Options/Programable:

HCPC codes: K0848,K0849,K0850,K0851,K0852 ,K0853

Additional Coverage Criteria

The patient’s mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and

The patient has had a specialty evaluation performed by a PT/OT, or physician who documents the medical necessity for the wheelchair and its special features.

Documentation that a supplier employed ATP was directly involved

Allowables: $4,598.00-$6,584.40

The Power Groupings: contGroup 3 -Single Power Option HCPC codes: K0856,K0858

Additional Coverage Criteria The patient’s mobility limitation is due to a neurological condition, myopathy, or

congenital skeletal deformity; and

The patient requires a drive control interface other than a hand or chin-operated standard proportional joystick; or

The patient meets coverage criteria for a power tilt or recline seating system and it is being used on the wheelchair; and

The patient has had a specialty evaluation performed by a PT/OT, or physician who documents the medical necessity for the wheelchair and its special features

Documentation that a supplier employed ATP was directly involved

Allowables: $5,133.40-$6,369.00

The Power Groupings: cont.Group 3 -Multiple Power OptionsHCPC codes: K0861,K0862

Additional Coverage Criteria The patient’s mobility limitation is due to a neurological condition, myopathy, or

congenital skeletal deformity; and

The patient meets coverage criteria for a power tilt and recline seating system and the system is being used on the wheelchair; or

The patient uses a ventilator mounted on the wheelchair; and

The patient has had a specialty evaluation performed by a PT/OT, or physician who documents the medical necessity for the wheelchair and its special features

Documentation that a supplier employed ATP was directly involved

Allowables: $5,141.60-$6,369.00

The Power Groupings: cont.Group 4 -No Power Options

HCPC codes: K0868,K0869, K0870

Additional Coverage Criteria The patient’s mobility limitation is due to a neurological condition, myopathy, or

congenital skeletal deformity; and

The patient has had a specialty evaluation performed by a PT/OT, or physician who documents the medical necessity for the wheelchair and its special features.

Documentation that a supplier employed ATP was directly involved

Down coding Medicare does not reimburse for Group 4 power wheelchairs because the product performance is greater than what someone needs in the home. Since Medicare does not reimburse for Group 4 power wheelchairs these products will be reimbursed at the equivalent Group 3 code allowance when billed with the KX modifier.

Allowables: $4,598.00- $5,547.40

The Power Groupings: cont.Group 4- Single Power OptionHCPC codes: K0877,K0879

Additional Coverage Criteria The patient’s mobility limitation is due to a neurological condition, myopathy, or

congenital skeletal deformity; and

The patient has had a specialty evaluation performed by a PT/OT, or physician who documents the medical necessity for the wheelchair and its special features.

Documentation that a supplier employed ATS/ATP was directly involved

Down codingMedicare does not reimburse for Group 4 power wheelchairs because the product performance is greater than what someone needs in the home. Since Medicare does not reimburse for Group 4 power wheelchairs these products will be reimbursed at the equivalent Group 3 code allowance when billed with the KX modifier.

Allowables: $5,133.40- $6,369.00

The Power Groupings: contGroup 4 Multiple Power OptionsHCPC codes: K0884, K0886

Additional Coverage Criteria The patient’s mobility limitation is due to a neurological condition, myopathy, or

congenital skeletal deformity; and

The patient has had a specialty evaluation performed by a PT/OT, or physician who documents the medical necessity for the wheelchair and its special features.

Documentation that a supplier employed ATP was directly

Down codingMedicare does not reimburse for Group 4 power wheelchairs because the product performance is greater than what someone needs in the home. Since Medicare does not reimburse for Group 4 power wheelchairs these products will be reimbursed at the equivalent Group 3 code allowance when billed with the KX modifier.

Allowables: $5,141.60- $6,369.00

Advocacy in Action!Equipping the called

Watch for those misleading ads…

FREE Or little to no cost

MEDICAREwith secondary insurance

POWER WHEELCHAIRS!!!!

Read the fine print:

You must first qualify medically, and

Haven’t had one in the last 5 years, and

Need to get around in your home, and…

Advocacy in Action!Equipping the called!

…and educate yourself and others!

Decreasing fraud and abuse is everyone’s business!

Power wheel chair cost in FY2003 hit all time high of $1.2 billion.

~With additional legislation and supplier standards

in place the provisioning of power chairs has declined to $686 million FY2007.

Advocacy in Action!Equipping the called!

Ohio Governor’s Office

Web site: http://www.governor.ohio.gov

Your elected officials:

Ohio Senate Districts

Web site: http://www.legislature.state.oh.us/senate.cfm

Ohio House Districts:

Web site: http://www.house.state.oh.us/

Advocacy in Action!

Federal: Ohio U.S. Congressional Districts

Web site for the U.S. Senate: http://www.senate.gov/

Web site for the U.S. House of Representatives: http://www.house.gov/

Advocacy in Action!2009 Ohio legislative changes requiring action:

State Bundling of Therapy Services, Oxygen, transportation, some over the counter medications, and wheel chairs to balance the budget. Per diem increase of $3.91/bed/day

These provisions were added during the budget process by the Ohio General Assembly at the request of the Association of Ohio Philanthropic Homes, Housing and Services for the Aging, the Academy of Nursing Homes, and the Ohio Health Care Association.

It was believed that including these services in the overall package of skilled nursing facility services would lead to greater coordination and could speed access to services since consumers in these circumstances would no longer have to go obtain prior authorization from the Office of Ohio Health Plans within the Ohio Department of Job and Family Services (ODJFS).

Immediate documentation of resident impact is needed!

Patients who are not receiving the appropriate services should contact the Long

Term Care Ombudsman program administered by the Ohio Department of Aging. Direct the patients and/or their families to the "Long Term Care Consumer Guide" or they may call 1-800-282-1206for assistance.

Send letters from beneficiaries & their families concerning the impact of this legislation to elected officials.

Call or write your elected officials!

Advocacy in Action!(cont.)

Federal Legislation:

Eliminate “In the Home” Medicare coverage restriction111th CONGRESS

H. R. 3184 To amend title XVIII of the Social Security Act to eliminate the in the home restriction for Medicare coverage of mobility devices for individuals with expected long-term need IN THE HOUSE OF REPRESENTATIVES July 13, 2009

Call or write your elected officials!

Advocacy in Action!(cont.)Resource: www.congress.org/congressorg/megavote

MegaVote for August 16, 2010 in Ohio's 16th Congressional District:

Recent Congressional VotesHouse: Education Jobs and Medicaid Assistance Act

Editor's Note: The House is once again in recess and is scheduled to return on Tuesday, September 14. The Senate will return Monday, September 13.

Recent House VotesEducation Jobs and Medicaid Assistance Act- Vote Passed (247-161, 25 Not Voting)

On Tuesday, the House passed this bill to provide $16.1 billion to extend increased Medicaid assistance to states and $10 billion in funding for states to create or retain teachers' jobs. The bill was then sent to the president, who signed it into law on the same day.

Rep. John Boccieri voted YES.

Additional Resources…

National Counsel on Disabilities- www.ncd.gov/

Annual Compendium of Disability Statistics:

A tool that compiles disability statistics published by various federal agencies.

An invaluable resource for finding and using disability statistics

Link directly to the 160 pages at:

http://neweditions.net/statsrrtc/Compendium2009.pdf

More Resources…Assistive Technology of Ohio

A federally funded nonprofit organization housed at The Ohio State University.

http://www.atohio.org/index.html

Healthcare Spending and the Medicare Program from Medicare Payment Advisory Commission- Medpac June 2009

http://www.medpac.gov/documents/Jun09DataBookEntireReport.pdf

Health Care and Education Affordability Reconcilliation Act of 2010http://www.whitehouse.gov/blog/2010/03/23/whats-health-care-bill

Sonshine Medical Inc.6590 Middlebranch Ave NECanton, OH 44721330-491-0041www.sonshinemedical.com

Maryann Tomkins, PTA,ATP Maryann.Tomkins@neo.rr.com

Our Mission:

To share the love of Jesus Christ while providing the

highest quality products and service.

Our Statement of Values:

We honor God first, family second, and everything else third.

Quote of the Day:

Life is 10% what happens to you and 90% how you react to it.

-Charles Swindoll

It is an honor to serve with you!Thank you for…

Your attention!

Your service in working with those who are disabled!

Advocating and being a voice for the disabled!

YOU WILL RECEIVE YOUR CERTIFICATE OF COMPLETION WHEN YOU TURN IN THE COURSE EVALUATION FORM!